Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PLATE TUBULAR LOCKING 4 HOLE L50MM

Facility

$161.00

Service Code	HCPCS C1713
Hospital Charge Code	8046739
Hospital Revenue Code	278
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$92.86
Rate for Payer: Amerigroup Medicare	$73.17
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.45
Rate for Payer: Iowa Total Care Managed Medicaid	$91.96
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$72.45
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$93.32
Rate for Payer: Partners Health Alliance Commercial	$83.32
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99

PLATE TUBULAR LOCKING 4 HOLE L50MM

Facility

$161.00

Service Code	HCPCS C1713
Hospital Charge Code	8046739
Hospital Revenue Code	278
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

PLATE TUBULAR LOCKING 4 HOLE L50MM-1

Facility

$175.00

Service Code	HCPCS C1713
Hospital Charge Code	8046741
Hospital Revenue Code	278
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Aetna of IA Medicare	$99.75
Rate for Payer: Amerigroup Medicaid	$100.94
Rate for Payer: Amerigroup Medicare	$79.54
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$78.75
Rate for Payer: Iowa Total Care Managed Medicaid	$99.96
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Medical Associates Managed Medicare	$78.75
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: Molina Healthcare Managed Medicaid	$101.43
Rate for Payer: Partners Health Alliance Commercial	$90.56
Rate for Payer: United Healthcare Commercial	$157.50
Rate for Payer: United Healthcare Managed Medicare	$103.25

PLATE TUBULAR LOCKING 4 HOLE L50MM-1

Facility

$175.00

Service Code	HCPCS C1713
Hospital Charge Code	8046741
Hospital Revenue Code	278
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: United Healthcare Commercial	$157.50

PLATE TUBULAR LOCKING 6 HOLE L50MM

Facility

$271.00

Service Code	HCPCS C1713
Hospital Charge Code	8046740
Hospital Revenue Code	278
Min. Negotiated Rate	$121.95
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of IA Commercial	$243.90
Rate for Payer: Aetna of IA Medical Rental Products	$243.90
Rate for Payer: Aetna of IA Medicare	$154.47
Rate for Payer: Amerigroup Medicaid	$156.31
Rate for Payer: Amerigroup Medicare	$123.17
Rate for Payer: Cash Price	$216.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$203.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$121.95
Rate for Payer: Iowa Total Care Managed Medicaid	$154.80
Rate for Payer: Medical Associates Commercial	$203.25
Rate for Payer: Medical Associates Managed Medicare	$121.95
Rate for Payer: Midlands Choice Commercial	$189.70
Rate for Payer: Molina Healthcare Managed Medicaid	$157.07
Rate for Payer: Partners Health Alliance Commercial	$140.24
Rate for Payer: United Healthcare Commercial	$243.90
Rate for Payer: United Healthcare Managed Medicare	$159.89

PLATE TUBULAR LOCKING 6 HOLE L50MM

Facility

$271.00

Service Code	HCPCS C1713
Hospital Charge Code	8046740
Hospital Revenue Code	278
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of IA Commercial	$243.90
Rate for Payer: Aetna of IA Medical Rental Products	$243.90
Rate for Payer: Cash Price	$216.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$203.25
Rate for Payer: Medical Associates Commercial	$203.25
Rate for Payer: Midlands Choice Commercial	$189.70
Rate for Payer: United Healthcare Commercial	$243.90

PLEURAL EFFUSION WITH CC

Facility

$11,090.87

Service Code	MSDRG 187
Min. Negotiated Rate	$10,930.13
Max. Negotiated Rate	$11,090.87
Rate for Payer: Amerigroup Medicaid	$11,037.29
Rate for Payer: Iowa Total Care Managed Medicaid	$10,930.13
Rate for Payer: Molina Healthcare Managed Medicaid	$11,090.87

PLEURAL EFFUSION WITH MCC

Facility

$14,432.77

Service Code	MSDRG 186
Min. Negotiated Rate	$14,223.60
Max. Negotiated Rate	$14,432.77
Rate for Payer: Amerigroup Medicaid	$14,363.04
Rate for Payer: Iowa Total Care Managed Medicaid	$14,223.60
Rate for Payer: Molina Healthcare Managed Medicaid	$14,432.77

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$6,182.74

Service Code	MSDRG 188
Min. Negotiated Rate	$6,093.13
Max. Negotiated Rate	$6,182.74
Rate for Payer: Amerigroup Medicaid	$6,152.87
Rate for Payer: Iowa Total Care Managed Medicaid	$6,093.13
Rate for Payer: Molina Healthcare Managed Medicaid	$6,182.74

pneumococcal 13-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$434.50

Service Code	HCPCS 90670
Hospital Charge Code	10429979
Hospital Revenue Code	259
Min. Negotiated Rate	$304.15
Max. Negotiated Rate	$391.05
Rate for Payer: Aetna of IA Commercial	$391.05
Rate for Payer: Aetna of IA Medical Rental Products	$391.05
Rate for Payer: Cash Price	$347.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$325.87
Rate for Payer: Medical Associates Commercial	$325.87
Rate for Payer: Midlands Choice Commercial	$304.15
Rate for Payer: United Healthcare Commercial	$391.05

pneumococcal 13-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$434.50

Service Code	HCPCS 90670
Hospital Charge Code	10429979
Hospital Revenue Code	259
Min. Negotiated Rate	$195.52
Max. Negotiated Rate	$400.65
Rate for Payer: Aetna of IA Commercial	$391.05
Rate for Payer: Aetna of IA Medical Rental Products	$391.05
Rate for Payer: Aetna of IA Medicare	$247.66
Rate for Payer: Amerigroup Medicaid	$250.62
Rate for Payer: Amerigroup Medicare	$197.48
Rate for Payer: Cash Price	$347.60
Rate for Payer: Cash Price	$347.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$325.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$195.52
Rate for Payer: Iowa Total Care Managed Medicaid	$248.18
Rate for Payer: Medical Associates Commercial	$325.87
Rate for Payer: Medical Associates Managed Medicare	$195.52
Rate for Payer: Midlands Choice Commercial	$304.15
Rate for Payer: Molina Healthcare Managed Medicaid	$251.83
Rate for Payer: Partners Health Alliance Commercial	$224.85
Rate for Payer: United Healthcare Commercial	$391.05
Rate for Payer: United Healthcare Managed Medicare	$256.35
Rate for Payer: Wellmark IA HMO WHPI	$363.72
Rate for Payer: Wellmark IA PPO	$400.65

pneumococcal 20-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$457.27

Service Code	HCPCS 90677
Hospital Charge Code	23914697
Hospital Revenue Code	259
Min. Negotiated Rate	$320.09
Max. Negotiated Rate	$411.54
Rate for Payer: Aetna of IA Commercial	$411.54
Rate for Payer: Aetna of IA Medical Rental Products	$411.54
Rate for Payer: Cash Price	$365.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$342.95
Rate for Payer: Medical Associates Commercial	$342.95
Rate for Payer: Midlands Choice Commercial	$320.09
Rate for Payer: United Healthcare Commercial	$411.54

pneumococcal 20-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$457.27

Service Code	HCPCS 90677
Hospital Charge Code	23914697
Hospital Revenue Code	259
Min. Negotiated Rate	$205.77
Max. Negotiated Rate	$411.54
Rate for Payer: Aetna of IA Commercial	$411.54
Rate for Payer: Aetna of IA Medical Rental Products	$411.54
Rate for Payer: Aetna of IA Medicare	$260.64
Rate for Payer: Amerigroup Medicaid	$263.75
Rate for Payer: Amerigroup Medicare	$207.83
Rate for Payer: Cash Price	$365.81
Rate for Payer: Cash Price	$365.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$342.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$205.77
Rate for Payer: Iowa Total Care Managed Medicaid	$261.19
Rate for Payer: Medical Associates Commercial	$342.95
Rate for Payer: Medical Associates Managed Medicare	$205.77
Rate for Payer: Midlands Choice Commercial	$320.09
Rate for Payer: Molina Healthcare Managed Medicaid	$265.03
Rate for Payer: Partners Health Alliance Commercial	$236.64
Rate for Payer: United Healthcare Commercial	$411.54
Rate for Payer: United Healthcare Managed Medicare	$269.79
Rate for Payer: Wellmark IA HMO WHPI	$363.72
Rate for Payer: Wellmark IA PPO	$400.65

pneumococcal 23-valent vaccine Inj Sol 0.5ml [VDMC]

Facility

$227.88

Service Code	HCPCS 90732
Hospital Charge Code	10414054
Hospital Revenue Code	259
Min. Negotiated Rate	$159.51
Max. Negotiated Rate	$205.09
Rate for Payer: Aetna of IA Commercial	$205.09
Rate for Payer: Aetna of IA Medical Rental Products	$205.09
Rate for Payer: Cash Price	$182.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.91
Rate for Payer: Medical Associates Commercial	$170.91
Rate for Payer: Midlands Choice Commercial	$159.51
Rate for Payer: United Healthcare Commercial	$205.09

pneumococcal 23-valent vaccine Inj Sol 0.5ml [VDMC]

Facility

$227.88

Service Code	HCPCS 90732
Hospital Charge Code	10414054
Hospital Revenue Code	259
Min. Negotiated Rate	$80.12
Max. Negotiated Rate	$205.09
Rate for Payer: Aetna of IA Commercial	$205.09
Rate for Payer: Aetna of IA Medical Rental Products	$205.09
Rate for Payer: Aetna of IA Medicare	$129.89
Rate for Payer: Amerigroup Medicaid	$131.44
Rate for Payer: Amerigroup Medicare	$103.57
Rate for Payer: Cash Price	$182.30
Rate for Payer: Cash Price	$182.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$102.54
Rate for Payer: Iowa Total Care Managed Medicaid	$130.16
Rate for Payer: Medical Associates Commercial	$170.91
Rate for Payer: Medical Associates Managed Medicare	$102.54
Rate for Payer: Midlands Choice Commercial	$159.51
Rate for Payer: Molina Healthcare Managed Medicaid	$132.08
Rate for Payer: Partners Health Alliance Commercial	$117.93
Rate for Payer: United Healthcare Commercial	$205.09
Rate for Payer: United Healthcare Managed Medicare	$134.45
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

PNEUMOTHORAX WITH CC

Facility

$9,245.40

Service Code	MSDRG 200
Min. Negotiated Rate	$9,111.40
Max. Negotiated Rate	$9,245.40
Rate for Payer: Amerigroup Medicaid	$9,200.73
Rate for Payer: Iowa Total Care Managed Medicaid	$9,111.40
Rate for Payer: Molina Healthcare Managed Medicaid	$9,245.40

PNEUMOTHORAX WITH MCC

Facility

$14,058.95

Service Code	MSDRG 199
Min. Negotiated Rate	$13,855.19
Max. Negotiated Rate	$14,058.95
Rate for Payer: Amerigroup Medicaid	$13,991.02
Rate for Payer: Iowa Total Care Managed Medicaid	$13,855.19
Rate for Payer: Molina Healthcare Managed Medicaid	$14,058.95

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$7,652.14

Service Code	MSDRG 201
Min. Negotiated Rate	$7,541.24
Max. Negotiated Rate	$7,652.14
Rate for Payer: Amerigroup Medicaid	$7,615.17
Rate for Payer: Iowa Total Care Managed Medicaid	$7,541.24
Rate for Payer: Molina Healthcare Managed Medicaid	$7,652.14

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$11,365.61

Service Code	MSDRG 917
Min. Negotiated Rate	$11,200.89
Max. Negotiated Rate	$11,365.61
Rate for Payer: Amerigroup Medicaid	$11,310.70
Rate for Payer: Iowa Total Care Managed Medicaid	$11,200.89
Rate for Payer: Molina Healthcare Managed Medicaid	$11,365.61

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$5,820.18

Service Code	MSDRG 918
Min. Negotiated Rate	$5,735.82
Max. Negotiated Rate	$5,820.18
Rate for Payer: Amerigroup Medicaid	$5,792.06
Rate for Payer: Iowa Total Care Managed Medicaid	$5,735.82
Rate for Payer: Molina Healthcare Managed Medicaid	$5,820.18

poliovirus vaccine, inactivated - Sus MDV [VDMC]

Facility

$98.56

Service Code	HCPCS 90713
Hospital Charge Code	21494404
Hospital Revenue Code	259
Min. Negotiated Rate	$68.99
Max. Negotiated Rate	$88.70
Rate for Payer: Aetna of IA Commercial	$88.70
Rate for Payer: Aetna of IA Medical Rental Products	$88.70
Rate for Payer: Cash Price	$78.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.92
Rate for Payer: Medical Associates Commercial	$73.92
Rate for Payer: Midlands Choice Commercial	$68.99
Rate for Payer: United Healthcare Commercial	$88.70

poliovirus vaccine, inactivated - Sus MDV [VDMC]

Facility

$98.56

Service Code	HCPCS 90713
Hospital Charge Code	21494404
Hospital Revenue Code	259
Min. Negotiated Rate	$44.35
Max. Negotiated Rate	$88.70
Rate for Payer: Aetna of IA Commercial	$88.70
Rate for Payer: Aetna of IA Medical Rental Products	$88.70
Rate for Payer: Aetna of IA Medicare	$56.18
Rate for Payer: Amerigroup Medicaid	$56.85
Rate for Payer: Amerigroup Medicare	$44.79
Rate for Payer: Cash Price	$78.85
Rate for Payer: Cash Price	$78.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.35
Rate for Payer: Iowa Total Care Managed Medicaid	$56.30
Rate for Payer: Medical Associates Commercial	$73.92
Rate for Payer: Medical Associates Managed Medicare	$44.35
Rate for Payer: Midlands Choice Commercial	$68.99
Rate for Payer: Molina Healthcare Managed Medicaid	$57.12
Rate for Payer: Partners Health Alliance Commercial	$51.00
Rate for Payer: United Healthcare Commercial	$88.70
Rate for Payer: United Healthcare Managed Medicare	$58.15
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

polycarbophil 625 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10414125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: United Healthcare Commercial	$1.06

polycarbophil 625 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10414125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Aetna of IA Medicare	$0.67
Rate for Payer: Amerigroup Medicaid	$0.68
Rate for Payer: Amerigroup Medicare	$0.53
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.53
Rate for Payer: Iowa Total Care Managed Medicaid	$0.67
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Medical Associates Managed Medicare	$0.53
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: Molina Healthcare Managed Medicaid	$0.68
Rate for Payer: Partners Health Alliance Commercial	$0.61
Rate for Payer: United Healthcare Commercial	$1.06
Rate for Payer: United Healthcare Managed Medicare	$0.69

polyethylene glycol 3350 Oral Pwdr for Recon [VDMC]

Facility

$21.84

Service Code	HCPCS A9270
Hospital Charge Code	10414194
Hospital Revenue Code	259
Min. Negotiated Rate	$15.29
Max. Negotiated Rate	$19.66
Rate for Payer: Aetna of IA Commercial	$19.66
Rate for Payer: Aetna of IA Medical Rental Products	$19.66
Rate for Payer: Cash Price	$17.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.38
Rate for Payer: Medical Associates Commercial	$16.38
Rate for Payer: Midlands Choice Commercial	$15.29
Rate for Payer: United Healthcare Commercial	$19.66

Know your out-of-pocket cost for care.

All Charges